Infertility

Understanding Infertility

Myth or fact: If a couple is having trouble conceiving a child, the man should try wearing loose underwear? That’s a fact, according to a study on “Tight-fitting Underwear and Sperm Quality” published June 29, 1996, in the scientific journal The Lancet. Tight-fitting underwear–as well as hot tubs and saunas–is not recommended for men trying to father a child because it may raise testes temperature to a point where it interferes with sperm production.

But couples having difficulty getting pregnant can tell you the solution is almost never as simple as wearing boxers instead of briefs. Lisa (who asked that her last name not be used) tried for more than two years to get pregnant without success. “Everyone gave me advice,” she says. “My mother said I should just go to church and pray more. My friends said, ‘Try to relax and not think about it’ or ‘You’re just overstressed. You work too much.'”

Actually, psychological stress is more likely a result of infertility than the cause, according to Resolve, a nonprofit consumer organization specializing in infertility. “Fertility problems are a huge psychological stressor, a huge relationship stressor,” says Lisa Rarick, M.D., director of the Food and Drug Administration’s division of reproductive and urologic drug products.

So, while going on a relaxing vacation may temporarily relieve the stress that comes with fertility problems, a solution may require treatment by a health-care professional. Treatment with drugs such as Clomid or Serophene (both clomiphene citrate) or Pergonal, Humegon, Metrodin, or Fertinex (all menotropins) are used in some cases to correct a woman’s hormone imbalance. (See “Drug Supply Restored.”) Surgery is sometimes used to repair damaged reproductive organs. And in about 10 percent of cases, less conventional, high-tech options like in vitro fertilization are used.

Will the therapies work? “Talking about the success rate for fertility treatments is like saying, ‘What’s the chance of curing a headache?'” according to Benjamin Younger, M.D., executive director of the American Society for Reproductive Medicine. “It depends on many things, including the cause of the problem and the severity.” Overall, Younger says, about half of couples that seek fertility treatment will be able to have babies.

A Year Without Pregnancy

Infertility is defined as the inability to conceive a child despite trying for one year. The condition affects about 5.3 million Americans, or 9 percent of the reproductive age population, according to the American Society for Reproductive Medicine.

Ironically, the best protection against infertility is to use a condom while you are not trying to get pregnant. Condoms prevent sexually transmitted diseases, a primary cause of infertility.

Even a completely healthy couple can’t expect to get pregnant at the drop of a hat. Only 20 percent of women who want to conceive become pregnant in the first ovulation cycle they try, according to Younger.

To become pregnant, a couple must have intercourse during the woman’s fertile time of the month, which is right before and during ovulation. Because it’s tough to pinpoint the exact day of ovulation, having intercourse often during the approximate time maximizes the chances of conception.

After a year of frequent intercourse without contraception that doesn’t result in pregnancy, a couple should go to a health-care professional for an evaluation. In some cases, it makes sense to seek help for fertility problems even before a year is up.

A woman over 30 may wish to get an earlier evaluation. “At age 30, a woman begins a slow decline in her ability to get pregnant,” says Younger. “The older she gets, the greater her chance of miscarriage, too.” But a woman’s fertility doesn’t take a big drop until around age 40.

“A man’s age affects fertility to a much smaller degree and 20 or 30 years later than in a woman,” Younger says. Despite a decrease in sperm production that begins after age 25, some men remain fertile into their 60s and 70s.

A couple may also seek earlier evaluation if:

The woman isn’t menstruating regularly, which may indicate an absence of ovulation that would make it impossible for her to conceive without medical help. The woman has had three or more miscarriages (or the man had a previous partner who had had three or more miscarriages). The woman or man has had certain infections that sometimes affect fertility (for example, pelvic infection in a woman, or mumps or prostate infection in a man). The woman or man suspects there may be a fertility problem (if, for example, attempts at pregnancy failed in a previous relationship).

The Man or the Woman?

Impairment in any step of the intricate process of conception can cause infertility. For a woman to become pregnant, her partner’s sperm must be healthy so that at least one can swim into her fallopian tubes. An egg, released by the woman’s ovaries, must be in the fallopian tube ready to be fertilized. Next, the fertilized egg, called an embryo, must make its way through an open-ended fallopian tube into the uterus, implant in the uterine lining, and be sustained there while it grows. (See diagram.)

It is a myth that infertility is always a “woman’s problem.” Of the 80 percent of cases with a diagnosed cause, about half are based at least partially on male problems (referred to as male factors)–usually that the man produces no sperm, a condition called azoospermia, or that he produces too few sperm, called oligospermia.

Lifestyle can influence the number and quality of a man’s sperm. Alcohol and drugs–including marijuana, nicotine, and certain medications–can temporarily reduce sperm quality. Also, environmental toxins, including pesticides and lead, may be to blame for some cases of infertility.

The causes of sperm production problems can exist from birth or develop later as a result of severe medical illnesses, including mumps and some sexually transmitted diseases, or from a severe testicle injury, tumor, or other problem. Inability to ejaculate normally can prevent conception, too, and can be caused by many factors, including diabetes, surgery of the prostate gland or urethra, blood pressure medication, or impotence.

The other half of explained infertility cases are linked to female problems (called female factors), most commonly ovulation disorders. Without ovulation, eggs are not available for fertilization. Problems with ovulation are signaled by irregular menstrual periods or a lack of periods altogether (called amenorrhea). Simple lifestyle factors–including stress, diet, or athletic training–can affect a woman’s hormonal balance. Much less often, a hormonal imbalance can result from a serious medical problem such as a pituitary gland tumor.

Other problems can also lead to female infertility. If the fallopian tubes are blocked at one or both ends, the egg can’t travel through the tubes into the uterus. Such blockage may result from pelvic inflammatory disease, surgery for an ectopic pregnancy (when the embryo implants in the fallopian tube rather than in the uterus), or other problems, including endometriosis (the abnormal presence of uterine lining cells in other pelvic organs).

A medical evaluation may determine whether a couple’s infertility is due to these or other causes. If a medical and sexual history doesn’t reveal an obvious problem, like improperly timed intercourse or absence of ovulation, specific tests may be needed.

Tests for Both

The man’s evaluation focuses on the number and health of his sperm. The laboratory first examines a sperm sample under a microscope to check sperm number, shape and movement. Further tests may be needed to look for infection, hormonal imbalance, or other problems.

Male tests include:

X-ray: If damage to one or both of the vas deferens (the ducts in the male that transport the sperm to the penis) is known or suspected, an x-ray is taken to examine the organs. Mucus penetrance test: Test of whether the man’s sperm are able to swim through a drop of the woman’s fertile vaginal mucus on a slide (also used to test the quality of the woman’s mucus). Hamster-egg penetrance assay: Test of whether the man’s sperm will penetrate hamster egg cells with their outer cells removed, indicating somewhat their ability to fertilize human eggs.

For the woman, the first step in testing is to determine if she is ovulating each month. This can be done by charting changes in morning body temperature, by using an FDA-approved home ovulation test kit (which is available over the counter), or by examining cervical mucus, which undergoes a series of hormone-induced changes throughout the menstrual cycle.

Checks of ovulation can also be done in the physician’s office with simple blood tests for hormone levels or ultrasound tests of the ovaries. If the woman is ovulating, further testing will need to be done.

Common female tests include:

Hysterosalpingogram: An x-ray of the fallopian tubes and uterus after they are injected with dye, to show if the tubes are open and to show the shape of the uterus. Laparoscopy: An examination of the tubes and other female organs for disease, using a miniature light-transmitting tube called a laparoscope. The tube is inserted into the abdomen through a one-inch incision below the navel, usually while the woman is under general anesthesia. Endometrial biopsy: An examination of a small shred of uterine lining to see if the monthly changes in the lining are normal.

Some tests require participation of both partners. Samples of cervical mucus taken after intercourse can show whether sperm and mucus have properly interacted. Also, a variety of tests can show if the man or woman is forming antibodies that are attacking the sperm.

Drugs and Surgery

Depending on what the tests turn up, different treatments are recommended. Eighty to 90 percent of infertility cases are treated with drugs or surgery.

Therapy with the fertility drug Clomid or with a more potent hormone stimulator–Pergonal, Metrodin, Humegon, or Fertinex–is often recommended for women with ovulation problems. The benefits of each drug and the side effects, which can be minor or serious but rare, should be discussed with the doctor. Multiple births occur in 10 to 20 percent of births resulting from fertility drug use.

Other drugs, used under very limited circumstances, include Parlodel (bromocriptine mesylate), for women with elevated levels of a hormone called prolactin, and a hormone pump that releases gonadotropins necessary for ovulation.

If drugs aren’t the answer, surgery may be. Because major surgery is involved, operations to repair damage to the woman’s ovaries, fallopian tubes, or uterus are recommended only if there is a good chance of restoring fertility.

In the man, one infertility problem often treated surgically is damage to the vas deferens, commonly caused by a sexually transmitted disease, other infection, or vasectomy (male sterilization).

Natural Treatments

Doctors agree that eating a healthy balanced diet is the first step toward successful conception. But in some cases where conception is difficult, nutritional supplements may prove helpful. Here’s what is recommended.